Tomoyuki Irino

The impact of surgical outcome after pancreaticoduodenectomy in elderly patients

BackgroundThe elderly population has increased in many countries. Indications for cancer treatment in elderly patients have expanded, because surgical techniques and medical management have improved remarkably. Pancreaticoduodenectomy (PD) requires high-quality techniques and perioperative management methods. If it is possible for elderly patients to withstand an aggressive surgery, age should not be considered a contraindication for PD. Appropriate preoperative evaluation of elderly patients will lead to their safer management. The purpose of the present study was to evaluate the safety of PD in patients older than 75 years and to show the influence of advanced age on the morbidity and mortality associated with this operation.Patients and methodsSubjects were 98 patients who underwent PD during the time period from April 2005 to April 2011. During this study, 31 patients were 75 years of age or older (group A), and the other 67 patients were less than 75 years old (group B). Preoperative demographic and clinical data, surgical procedure, pathologic diagnosis, postoperative course and complication details were collected prospectively and they were analyzed in two group.ResultsThere was no statistical difference between patient groups in terms of gender, comorbidity, preoperative drainage, diagnosis, or laboratory data. Preoperative albumin values were lower in group A (P = 0.04). The mean surgical time in group A was 408.1 ± 73.47 min. Blood loss and blood transfusion were not significantly different between both groups. There was no statistical differences in mortality rate (P = 0.14), morbidity rate (P = 0.43), and mean length of hospital stay (P = 0.22) between both groups.Long-term survival was also no statistically significant difference between the two groups using the log-rank test (P = 0.10).ConclusionIt cannot be ignored that the elderly population is getting larger. We must investigate the management of elderly patients after PD and prepare further for more experiences of PD. If appropriate surgical management is provided to elderly patients, we suggest that PD will lead to no adverse effects after surgery, and PD can be performed safely in elderly patients. We conclude that age should not be a contraindication to PD.

Endoscopic management of pancreatic duct injury by endoscopic stent placement: a case report and literature review

Recently, the diagnostic evaluation of pancreatic injury has improved dramatically. On the other hand, it is occasionally difficult to diagnose pancreatic injury, because there are no specific signs, symptoms, or laboratory findings. Radiological imaging also often fails to identify pancreatic injury in the acute phase. Delayed diagnosis results in significant morbidity and mortality. Most cases of pancreatic injury with suspicion or pancreatic duct disruption require surgery. Endoscopic retrograde cholangiopancreatography is one of the most accurate modalities for ductal evaluation and therapy and might enable one to avoid unnecessary surgery. We describe endoscopic management of pancreatic duct injury by endoscopic stent placement. A 45-year-old woman was admitted after a traffic accident. A computed tomography scan showed pancreatic parenchyma disruption at the pancreatic head. Endoscopic retrograde cholangiopancreatography demonstrated disruption of the pancreatic duct with extravasation into the peripancreatic fluid collection. A 5-French endoscopic nasopancreatic drainage (ENPD) tube was placed. Her symptoms dramatically improved. ENPD tube was exchanged for a 5-French 5-cm pancreatic stent. Subsequent follow-up CT revealed remarkable improvement. On the 26th day, the patient was discharged from the hospital without symptoms or complications. In this report, a pancreatic stent may lead to rapid clinical improvement and enable surgery to be avoided. On the other hand, the reported complications of long-term follow-up make the role of stenting uncertain. Thus, close attention should be paid to stenting management in the follow-up period. A pancreatic stent is useful for pancreatic ductal injury. If pancreatic ductal injury is managed appropriately, a pancreatic stent may improve the clinical condition, and also prevent unnecessary surgery.

Sentinel Node Mapping with Thermoresponsive Magnetic Nanoparticles in Rats

BACKGROUND In this study, we investigated the ability of magnetic resonance imaging (MRI) after interstitial administration of thermoresponsive magnetic nanoparticles to detect the sentinel lymph node (SLN). MATERIALS AND METHODS Postcontrast MRI scans were acquired following subcutaneous injection of thermoresponsive magnetic nanoparticles into the thoracic wall of rats. The signal-to-noise ratio of axillary lymph nodes was calculated to assess whether the SLN could be detected by MRI. In a second experiment, after injecting thermoresponsive magnetic nanoparticles, i.e., Therma-Max 36, Therma-Max 42, Therma-Max 55, and Ferridex, into the subserosa of the cecum of rats, the injection sites, the SLNs, and the distant lymph nodes were resected and examined histologically in order to determine which nanoparticles, if any, were specifically retained in the SLN. RESULTS MRI showed that the signal-to-noise ratio of axillary SLNs was significantly lower 24 h after injection of Therma-Max 42 than on the precontrast images (P < 0.05). Histologic evaluation revealed that Therma-Max 36 aggregated at body temperature and did not migrate to the SLN. Therma-Max 42, on the other hand, aggregated, and the particles became large enough to be retained in the SLNs. Therma-Max 55 and Ferridex did not aggregate, and they both migrated to the SLNs and the distant lymph nodes. CONCLUSIONS The results of this study showed that thermoresponsive magnetic nanoparticles could be targeted to the SLN by adjusting the temperature at which they aggregate, and that they could be used as a contrast agent for SLN mapping by MRI.

Age and body mass index: significant predictive factors for successful laparoscopic antireflux surgery.

PurposeLaparoscopic antireflux surgery (LARS) is a feasible treatment for gastroesophageal reflux disease (GERD) patients, but it is unclear who will benefit from the surgery. This study investigated patients’ GERDspecific quality of life (GsQOL) and analyzed the factors leading to the performance of successful LARS.MethodsTwenty-six (57.8%) of 45 consecutive patients who underwent LARS for GERD during the last decade were enrolled. All patients were evaluated by 24-h pH monitoring, esophageal manometry, esophagogastro-duodenoscopy and physical examinations. GsQOL was assessed by a visual analog scale, and the difference between the pre- and postoperative scores was defined as the visual analog scale improvement score (VASIS). The patients were classified into three groups based on the VASIS, and their clinical factors and surgical outcomes were compared.ResultsThe high VASIS group patients (>70 VASIS; Excellent group) patients were significantly younger and obese in comparison to low the VASIS group (<30 VASIS; Poor group) consisting of older nonobese patients (P < 0.05). A multiple regression analysis revealed that age <60 years and body mass index (BMI) >25 kg/m2 were significant factors that affected postoperative GsQOL. No other clinical or surgical factors had any influence on the postoperative GsQOL.ConclusionThese results suggest that age and BMI can be predictive factors for the performance of successful LARS.

Clinicopathological feature of extrahepatic cholangiocarcinoma without jaundice: A single-center experience

BACKGROUND/AIMS The prognosis remains unsatisfactory even if the patient undergoes extensive surgery, which is the only curative treatment for these tumors. Therefore, early detection and diagnosis are needed to improve long-term survival. To investigate the clinicopathological feature of extrahepatic cholangiocarcinoma in patients presenting without jaundice compared with the features of tumors in patients presenting with jaundice. METHODOLOGY This was a retrospective study of 50 patients resected for extrahepatic cholangiocarcinoma. There were 15 non-jaundiced (Group A) and 35 jaundiced patients (Group B). Data on demographic and clinical features, surgical procedures and pathological diagnoses were collected retrospectively. RESULTS Preoperative mean serum levels of total bilirubin, aspartate aminotransferase, alanine aminotransaminase, alkaline phosphatase and gamma-glutamyltranspeptidase were statistically different between the groups. There was also a significant difference in the location of tumors. The distal tumors occurred in 9 non-jaundiced and 31 jaundiced patients (p=0.048). There were no significant differences between the characteristics and preoperative laboratory data of the patients with perihilar tumors and those with distal tumors. CONCLUSIONS We believe that finding the disease in asymptomatic and non-jaundiced patients is very important for their prognosis. Further studies are needed and efforts should also continue to identify patients with suspicious findings.

Bouveret’s syndrome with a concomitant incidental T1 gallbladder cancer

Bouveret’s syndrome, which is a gastric outlet obstruction caused by a gallstone in the duodenum, is a rare complication of gallstone disease. We report a case of Bouveret’s syndrome in an 81-year-old woman who also exhibited incidental gallbladder cancer. She was admitted to our hospital complaining of upper abdominal pain and vomiting. A computed tomography examination showed a cholecystoduodenal fistula, a large impacted stone at the gastric outlet, and a dilated stomach. She was diagnosed as having Bouveret’s syndrome. The patient underwent an upper gastrointestinal endoscopy and a mechanical lithotripsy was successfully performed for the stone. She then underwent a cholecystectomy with primary closure of the duodenal fistula. An intra-operative histopathology examination revealed severe cholecystitis with an adenocarcinoma in part of the gallbladder. Gallbladder bed resection and regional lymph node dissection were also performed. To the best of our knowledge, this is the first published report of a case in which Bouveret’s syndrome and gallbladder cancer co-existed.

Reply to comment on “Are body mass index and performance status enough to assess the nutritional and functional status of elderly patients undergoing gastric cancer surgery?”

We thank Lidoriki et al. for their interest in our paper [1], which investigated the feasibility of gastrectomy for very elderly patients (≥ 85 years of age). The results of our study suggest that chronological age alone is not a valid reason for avoiding gastrectomy, and a comprehensive assessment is necessary to determine the optimum treatment strategy for elderly patients with gastric cancer. The results of a multivariate analysis, which did not identify chronological age as an independent prognostic factor, also support our view that gastrectomy should be considered regardless of chronological age as long as the physical capacity is maintained [1]. We partially agree with Lidoriki et al. that sarcopenia and frailty have recently emerged as significant prognostic factors for the postoperative outcomes of geriatric patients. Indeed, previous studies have clearly demonstrated a significant relationship between sarcopenia and postoperative complications [2]; however, whether or not this relationship holds true in terms of the long-term post-surgical survival remains controversial. A recent meta-analysis included only two studies with a long-term survival assessment, and the results were inconsistent [2]. We also investigated the impact of sarcopenia on the long-term outcomes in elderly gastric cancer patients and reported adverse effects on the survival outcomes [3], which is consistent with the findings of a study conducted by Zhuang et al. [4]. In addition, Kudou et al. reported a strong relationship between the postoperative development of sarcopenia and poor long-term survival outcome [5]. Conversely, Tegels et al. [6] reported no association of sarcopenia with the postoperative morbidity and survival outcomes. Such inconsistency among studies most likely reflects the different definitions of sarcopenia and elderly in each study. Consequently, sarcopenia cannot be considered a robust prognosticator for elderly patients undergoing gastrectomy, although this issue remains to be fully investigated. Therefore, it is not necessary to include sarcopenia as a covariate for multivariable analyses of the long-term survival outcomes. In conclusion, while sarcopenia should definitely be integrated into the preoperative assessment tool for elderly patients, robust evidence needs to be gathered concerning both the early postoperative outcomes and the long-term survival.

Esophagojejunal anastomotic leakage following gastrectomy for gastric cancer

Esophagojejunal anastomotic leakage (EJAL) is a serious complication of total or proximal gastrectomy for gastric cancer, with a reported incidence of 2.1–14.6% and mortality of up to 50%. EJAL is an independent prognostic factor for the poor survival of gastric cancer patients. Meticulous surgical techniques, experience with anastomotic devices, and a thorough understanding of various risk factors and preventive measures are essential and early diagnosis is critical for preventing EJAL-related death. Patients with suspected EJAL must be evaluated promptly, but contrast swallow is not recommended. There is no standard treatment strategy for EJAL, although conservative treatment with drainage and nutritional support is the most common approach. Effective endoscopic treatments have been reported but need further validation. Surgical treatment is associated with high mortality but should be considered to prevent death from suboptimal EJAL management, for patients with severe sepsis or when conservative treatment has failed.

Feasibility of Laparoscopic Distal Gastrectomy for Stage I Gastric Cancer in Patients Outside of Clinical Trials

BackgroundRandomized controlled trials, including the Japan Clinical Oncology Group (JCOG) 0912 trial, have shown the safety of laparoscopy-assisted distal gastrectomy (LADG) for select healthy patients. It is unclear whether LADG is feasible in patients who do not meet trial eligibility criteria.MethodsThe present study retrospectively reviewed 547 patients with clinical stage I gastric cancer who underwent distal or pylorus-preserving gastrectomy. Of these, 185 were identified as not fulfilling the eligibility criteria of JCOG 0912; the short-term surgical outcomes between LADG and open distal gastrectomy (ODG) were compared in this group before and after propensity score matching.ResultsPatients who were not eligible for inclusion in the trial comprised 33.8% of the total. After matching, there were 59 patients each in the LADG and ODG groups, with an improved balance of confounding factors between the two groups. LADG was associated with significantly longer operation time, less blood loss, and shorter postoperative hospital stay than ODG. The rate of overall postoperative complications of Clavien–Dindo Grade II or higher did not differ significantly between the LADG and ODG groups (23.7 vs. 18.6%, respectively; p = 0.653). The incidence of pneumonia (6.8 vs. 5.1%), intra-abdominal infectious complications (5.1 vs. 3.4%), and stasis syndrome (5.1 vs. 3.4%) was also comparable between the two groups.ConclusionLADG was as safe as ODG in patients who did not meet the eligibility criteria of JCOG 0912. LADG could be a standard treatment option for patients with stage I gastric cancer, regardless of their general condition.

Pancreaticoduodenectomy for gastric cancer

Pancreaticoduodenectomy (PD) is performed to achieve an R0 resection for gastric cancer with pancreatic and/or duodenal invasion. Several retrospective case series have been published, but the sample cohorts in each study were heterogeneous and small. Moreover, the absence of prospective studies results in a lack of solid evidence that will help determine who can benefit from this procedure. Although the morbidity and mortality of PD have been reported by most studies to be acceptable and that the procedure is feasible, these remained to be much higher than those of standard gastrectomy. Therefore, careful selection of patients should be considered. Based on a review of previous case series and our own experience, PD appears to be beneficial to patients with gastric cancer with pancreatic invasion when R0 resection is possible. In addition, multidisciplinary treatment such as neoadjuvant chemotherapy, is anticipated to improve survival. Nevertheless, considering that prospective randomized studies are difficult to perform, a large-scale multicenter retrospective cohort study is required to evaluate this highly invasive procedure.